Will politicians who blame mass shootings on mental illness expand Medicaid?

"If you care about mental health, expand Medicaid."

So said Beto O'Rourke, the Democratic nominee for governor of Texas, in a tweet last week that went viral. O'Rourke was responding to events in recent weeks that included a mass shooting at a grocery store in Buffalo, New York, that left 10 Black people dead at the hands of a white supremacist, and a mass shooting at a majority-Latino elementary school in Uvalde, Texas, that left 19 students and two teachers dead in the third-deadliest school shooting in United States history. 

The tragedies could have been prevented by more stringent gun laws, but Republican politicians have resisted calls for gun reform, even as mass shootings and threats have continued to occur almost daily. Instead, GOP elected officials like Texas Gov. Greg Abbott — who O'Rourke notably called out for hypocrisy in the days after the Uvalde shooting — have blamed the recent mass shootings on mental illness.

"We, as a state, we, as a society, need to do a better job with mental health," Abbott said after the Uvalde shooting. "Anybody who shoots somebody else has a mental health challenge, period."

Yet Abbott has refused to champion measures that would improve access to mental health care for Texans, like Medicaid expansion. To date, the state's Republican-controlled legislature has refused to expand the joint federal-state health care program for low-income people under the Affordable Care Act, along with 11 other states, a total of eight of them in the South. The Republican-controlled North Carolina state Senate recently passed a bill to expand Medicaid in the state, but state House Speaker Tim Moore (R) said there's little appetite for Medicaid expansion in his chamber.

As it stands now, Texas is the state that has the nation's biggest coverage gap. An estimated 771,000 residents are ineligible for Medicaid but also ineligible for premium subsidies to offset the cost of private coverage, making it difficult for them to access mental health care. Nationwide, most of those who fall in the coverage gap live in the South, and 60% are people of color.

Medicaid is the nation's top payer for mental health and substance use care, covering more than one in four adults with serious mental health issues, according to the National Alliance on Mental Illness. In states that have expanded the program, people are more likely to have access to care and are less likely to skip medications due to cost. Additionally, research has found a link between Medicaid expansion and decreased suicide rates; suicidality has been found to be a strong predictor of mass shootings.

However, mental health advocates are raising concerns about politicians' efforts to link mass shootings to mental illness. This week, 60 national organizations including the American Psychiatric Association and the National Alliance on Mental Illness issued a statement condemning "false and harmful attempts" to link gun violence to mental illness:

Attempts to connect mental illness to mass shootings are a distraction that inflicts enormous damage by taking attention from solutions that could actually prevent such events. This perpetuates a false narrative that encourages stigmatization of and discrimination against the millions of Americans living with mental health conditions who are more likely to be victims of violence than perpetrators of it. In fact, persons with mental illness account for a very small portion of gun violence. While mental health conditions are common in countries across the globe, the United States is the only country where mass shootings have become disturbingly commonplace. In fact, firearms are now the leading cause of death for children and adolescents in the United States. Not coincidentally, the U.S. is also alone in making firearms widely available with few restrictions.

Gun violence is a public health crisis, and the trauma and fear caused by mass shootings significantly worsen Americans' mental health. A large majority of adults in the United States experience stress associated with mass shootings, and a third of U.S. adults say that fear of mass shootings stops them from going to certain places and events. Moreover, research has shown that victims and members of affected communities experience increases in posttraumatic stress symptoms, depression, and other signs of psychological concerns. Other studies have found that, after previous mass shootings, youth felt less safe and more fearful. These findings, many of which are unsurprising, make it all the more important to take urgent action to prevent these shootings, particularly in light of our nation's ongoing youth mental health crisis.

While the organizations say they welcome continued bipartisan efforts to improve the nation's mental health and substance abuse systems, they note that the epidemic of gun violence requires policymakers to promote gun safety.

But increasing access to mental health care through Medicaid expansion would undoubtedly help the survivors of mass shootings and the wider communities traumatized by such events. It would also help reduce racial disparities in who can access care related to such shootings. While over 97% of perpetrators of mass shootings are men, Black people are overrepresented, accounting for just over 13% of the U.S. population but 21% of mass shooters. White people make up 76% of the U.S. population and 52% of mass shooters, while Latinos make up over 18% of the U.S. population and 8% of mass shooters. However, three-quarters of the victims of mass shootings — defined as those that leave four or more people injured or dead — are Black, meaning Black communities across the South and nation bear a disproportionately heavy trauma burden related to such shootings.

As mental health advocate David Kendrick Jr. noted following the Buffalo grocery store massacre, mass shooting survivors suffer mental wounds resembling those of war survivors. And people who survived previous atrocities like the Charleston Church Massacre have been re-traumatized by the recent shootings and might also be in need of care that can be difficult to access; South Carolina is also among the states where lawmakers have refused to expand Medicaid.